[Management strategy of femoral artery pseudoaneurysm combined with infectious wounds].

Objective: To investigate the surgical treatment methods of femoral artery pseudoaneurysm combined with infectious wounds and to evaluate the clinical effects. Methods: The retrospective observational research method was used. Twelve patients with femoral artery pseudoaneurysm combined with infectious wounds who met the inclusion criteria were admitted to Nanjing University of Chinese Medicine Wuxi Integrated Traditional Chinese and Western Medicine Hospital (Affiliated Hospital of Jiangnan University) from October 2014 to September 2022, including 6 males and 6 females, aged from 46 to 78 years. In the primary operation, debridement, tumor resection, and artery suture/venous grafting to repair the artery/artery ligation were performed, and the wound area after tumor resection ranged from 4.0 cm×1.5 cm to 12.0 cm×6.5 cm. Wounds that could be sutured were treated with tension reduction suture and extracutaneous continuous vacuum sealing drainage (VSD), while large wounds that could not be sutured were treated with VSD to control infection. In the secondary operation, tension reduction suture was performed to repair the wounds that could be sutured; large wounds were repaired with adjacent translocated flaps with area of 9.0 cm×5.0 cm to 15.0 cm×7.0 cm. Additionally, when the length of the exposed femoral artery was equal to or over 3.0 cm, the wounds were repaired with additional rectus femoris muscle flap with length of 15.0 to 18.0 cm. The donor areas of the flaps were directly sutured. The wound with artery ligation was treated with stamp skin grafting and continuous VSD. The bacterial culture results of the wound exudate samples on admission were recorded. The intraoperative blood loss, the location of femoral artery rupture, the artery treatment method, and the wound repair method in the primary operation were recorded, and the durations of catheter lavage, catheter drainage, and VSD treatment, and the drainage volume after the operation were recorded. The repair method of wounds in the secondary operation, the durations of catheter drainage and VSD treatment, and the total drainage volume after the operation were recorded. The survivals of flap/muscle flap/stamp skin grafts were observed, and the wound healing time was recorded. Follow-up after discharge was performed to evaluate the quality of wound healing and the walking function and to check whether the pulsatile mass disappeared. B-ultrasound or computed tomography angiography (CTA) was performed again to observe potential pseudoaneurysm recurrence and evaluate the patency of blood flow of the femoral artery. Results: The bacterial culture results of wound exudate samples of all the patients were positive on admission. The blood loss was 150 to 750 mL in the primary operation. The arterial ruptures were located in the femoral artery in 8 cases, in the external iliac artery in 2 cases, and in the femoral arteriovenous fistula in 2 cases. Six cases received direct artery suture, 4 cases received autologous great saphenous vein grafting to repair the artery, 1 case received autologous great saphenous vein bypass surgery, and 1 case received artery ligation. The primary wound suture was performed in 4 cases, along with catheter lavage for 3 to 5 days, catheter drainage for 4 to 6 days, VSD treatment for 5 to 7 days, and a total drainage volume of 80 to 450 mL after the surgery. In the secondary operation, the wounds were sutured directly in 3 cases along with catheter drainage for 2 to 3 days, the wound was repaired with scalp stamp skin graft and VSD treatment for 5 days in 1 case, the wounds were repaired with adjacent translocated flaps in 2 cases with catheter drainage for 2 to 3 days, and the wounds were repaired with rectus femoris muscle flaps+adjacent translocated flaps in 2 cases with catheter drainage for 3 to 5 days . The total drainage volume after the secondary operation ranged from 150 to 400 mL. All the skin flaps/muscle flaps/skin grafts survived after operation. The wound healing time ranged from 15 to 36 days after the primary operation. Follow-up of 2 to 8 months after discharge showed that the wounds of all patients healed well. One patient who underwent femoral artery ligation had calf amputation due to foot ischemic necrosis, and the rest of the patients regained normal walking ability. The pulsatile mass disappeared in inguinal region of all patients. B-ultrasound or CTA re-examination in 6 patients showed that the blood flow of femoral artery had good patency, and there was no pseudoaneurysm recurrence. Conclusions: Early debridement, tumor resection, and individualized artery treatment should be performed in patients with femoral artery pseudoaneurysm combined with infected wounds. Besides, proper drainage and personalized repair strategy should be conducted according to the wound condition to achieve a good outcome.

[Effects of porcine urinary bladder matrix on motility and polarization of bone marrow-derived macrophages in mice].

Objective: To explore the effects of porcine urinary bladder matrix (UBM) on the motility and polarization of bone marrow-derived macrophages in mice, so as to provide evidence for the rational selection of stent in clinical wound repair. Methods: The method of experimental research was used. The microstructure of porcine UBM and absorbable dressing was observed under scanning electron microscope. Polyacrylamide gel electrophoresis was used to observe the protein distribution of the two stent extracts. The primary macrophages were induced from bone marrow-derived cells isolated from six 6-8-week-old male C57BL/6J mice (mouse age, sex, and strain, the same below) and identified. Three batches of macrophages were divided into porcine UBM extract group and absorbable dressing extract group. The cells in each group were cultured with Dulbecco's modified Eagle medium/F12 medium containing the corresponding extracts. The cell migration rate was detected and calculated on 1, 3, and 7 d after scratching by scratch test. The number of migrated cells at 12 and 24 h of culture was detected by Transwell experiment. The percentages of CD206 and CD86 positive cells at 24 h of culture was detected by flow cytometer. The numbers of sample in the above cell experiments were all 3. An incision was prepared on the left and right back of twelve mice, respectively. The left incision of each mouse was included in porcine UBM group and the right incision was included in absorbable dressing group, and the corresponding stents were implanted into the incisions respectively. On post operation day (POD) 7 and 14, the number of inflammatory cells infiltrated in the stent was detected by hematoxylin-eosin staining; the number of F4/80, transforming growth factor-ß1 (TGF-ß1), vascular endothelial growth factor (VEGF), and matrix metalloprotein-9 (MMP-9) positive cells and type Ⅰ collagen deposition in stents were observed by immunohistochemistry; the percentages of F4/80, CD86, and CD206 positive cells were observed by immunofluorescence staining. The numbers of sample in the above animal experiments were all 6. Data were statistically analyzed with analysis of variance for factorial design, analysis of variance for repeated measurement, and independent sample t test. Results: Porcine UBM has a dense basement membrane structure on one side and porous propria containing a fibrous structures on the other. Both sides of the absorbable dressing had three-dimensional porous structure. In the molecular weight range of (50-70)×103, multiple non-type Ⅰ collagen bands appeared in the lanes of porcine UBM extract, while no obvious bands appeared in the lanes of absorbable dressing extract. It had been identified that mouse bone marrow-derived cells had been successfully induced into macrophages. The cell migration rates in porcine UBM extract group were significantly higher than those in absorbable dressing extract group on 1, 3, and 7 d after scratching (with t values of 15.31, 19.76, and 20.58, respectively, P<0.05). The numbers of migrated cells in porcine UBM extract group were significantly more than those in absorbable dressing extract group at 12 and 24 h of culture (with t values of 12.20 and 33.26, respectively, P<0.05). At 24 h of culture, the percentage of CD86 positive cells in porcine UBM extract group ((1.27±0.19)%) was significantly lower than (7.34±0.14)% in absorbable dressing extract group (t=17.03, P<0.05);the percentage of CD206 positive cells in porcine UBM extract group was (73.4±0.7)%, significantly higher than (32.2±0.5)% in absorbable dressing extract group (t=119.10, P<0.05). On POD 7 and 14, the numbers of inflammatory cells infiltrated in the stents in porcine UBM group was significantly more than those in absorbable dressing group (with t values of 6.58 and 10.70, respectively, P<0.05). On POD 7 and 14, the numbers of F4/80, TGF-ß1, VEGF, and MMP-9 positive cells in the stents in porcine UBM group were significantly more than those in absorbable dressing group (with t values of 46.11, 40.69, 13.90, 14.15, 19.79, 32.93, 12.16, and 13.21, respectively, P<0.05); type Ⅰ collagen deposition in the stents in porcine UBM group was more pronounced than that in absorbable dressing group; the percentages of CD206 positive cells in the stents in porcine UBM group were significantly higher than those in absorbable dressing group (with t values of 5.05 and 4.13, respectively, P<0.05), while the percentages of CD86 positive cells were significantly lower than those in absorbable dressing group (with t values of 20.90 and 19.64, respectively, P<0.05), and more M2-type macrophages were seen in the stents in porcine UBM group and more M1-type macrophages were seen in the stents in absorbable dressing group. Conclusions: Porcine UBM can enhance macrophage motility, induce M2 polarization and paracrine function, create a microenvironment containing growth factors such as TGF-ß1 and MMP-9 tissue remodeling molecules, and promote tissue regeneration and extracellular matrix remodeling in mice.

[Influence of porcine urinary bladder matrix and porcine acellular dermal matrix on wound healing of full-thickness skin defect in diabetic mice].

Objective: To compare the difference of pro-healing effect of porcine urinary bladder matrix (UBM) and porcine acellular dermal matrix (ADM) on full-thickness skin defect wounds in diabetic mice. Methods: Thirty-six type 2 diabetic BKS db/db mice aged 10 weeks were divided into UBM group and ADM group according to the random number table, with 18 mice in each group and preoperative molarity of non-fasting blood glucose higher than 16.6 mmol/L. A circular full-thickness skin defect wound with 6 mm in diameter was made on the back of each mouse, and porcine UBM and porcine ADM scaffolds were implanted into the wounds of both groups correspondingly. Immediately after operation and on post operation day (POD) 7, 14, and 28, wounds were observed generally. On POD 7, 14, and 28, 6 mice of each group were collected respectively to calculate the rate of wound epithelialization, and then the corresponding mice were sacrificed after calculation, and the wound tissue was harvested to make slices. Six slices of the mice in the 2 groups on POD 7 and 14 were respectively collected to stain with haematoxylin-eosin (HE), and 6 slices on POD 7 and 28 had Masson's staining, which were used to observe histopathological changes and scaffold degradation. On POD 7 and 14, 24 slices of each mouse in the 2 groups were collected respectively to detect alpha smooth muscle actin (α-SMA) and CD31 positive expression denoting the growth of myofibroblasts and neovessels respectively and observe the distribution and activation of macrophages with immunohistochemical staining. The wound tissue of mice in the 2 groups on POD 7 and 14 was harvested to detect mRNA expressions of fibroblast growth factor 2 (FGF-2), vascular endothelial growth factor (VEGF), platelet-derived growth factor (PDGF), and transforming growth factor ß(1) (TGF-ß(1)) by real-time fluorescence quantitative reverse transcription polymerase chain reaction. The sample number of above-mentioned indexes in each group at each time point was 6. Data were statistically analyzed with analysis of variance for factorial design, t test, and Bonferroni correction. Results: (1) General observation showed that integration of UBM scaffold into the wounds of mice in UBM group on most time points was superior, and integration of ADM scaffold into the wounds of mice in ADM group on most time points was inferior. On POD 28, epidermis still did not form in some region of scaffold surface of wounds of mice in ADM group, while wounds of mice in UBM group were completely epithelialized. On POD 7, 14, and 28, wound epithelialization rates of mice in UBM group were respectively (22.4±6.4)%, (68.6±12.4)%, and 100.0%, all significantly higher than (4.5±2.2)%, (23.6±4.6)%, and (64.2±13.2)% in ADM group (t=7.427, 9.665, 7.655, P<0.01). (2) HE staining and Masson's staining showed that a large number of cells appeared in wound scaffold of mice in UBM group on POD 7; cells distributed in the whole region of UBM scaffold on POD 14; dermal tissue with structure similar to normal skin formed in the wounds and the fibrous morph of UBM scaffolds disappeared on POD 28. Only a small number of cells appeared in inside of wound scaffolds of mice in ADM group on POD 7; on POD 14, cells were sparsely distributed in ADM scaffolds; on POD 28, the morph of originally robust collagen fiber of ADM scaffolds was still clear and visible. (3) On POD 7, a large number of accumulated myofibroblasts and neovessels appeared in the lower layers of scaffolds of wounds of mice in UBM group; on POD 14, evenly distributed myofibroblasts and neovessels appeared in the upper layers of UBM scaffolds, and most vessels were perfused. On POD 7 and 14, myofibroblasts were sparsely distributed in scaffolds of wounds of mice in ADM group with no or a few neovascular structures perfused unobviously. On POD 7 and 14, α-SMA positive expressions in scaffolds of wounds of mice in UBM group were significantly higher than those in ADM group (t=25.340, 6.651, P<0.01); CD31 positive expressions were also significantly higher than those in ADM group (t=34.225, 10.581, P<0.01). (4) On POD 7, a large number of macrophages appeared in the lower layers of scaffolds of wounds of mice in UBM group; on POD 14, macrophages infiltrated into the internal region of UBM scaffolds, and M2 polarization occured without M1 polarization. On POD 7, a small number of macrophages appeared in the bottom of scaffolds of wounds of mice in ADM group; on POD 14, macrophages were few in internal region of ADM scaffold, and neither M2 polarization nor M1 polarization occurred. (5) On POD 7 and 14, mRNA expressions of FGF-2, VEGF, PDGF, and TGF-ß(1) in the wound tissue of mice in UBM group were all significantly higher than those in ADM group (t=7.007, 14.770, 10.670, 8.939; 7.174, 7.770, 4.374, 4.501, P<0.01). Conclusions: Porcine UBM scaffold is better than porcine ADM in facilitating wound repair and dermis reconstruction of full-thickness skin defects in diabetic mice through the induction of myofibroblasts and macrophages immigration, the promotion of neovascularization and expression of pro-healing growth factors.

[Clinical efficacy and influencing factors of different modes of continuous negative pressure wound therapy on venous ulcer wounds of lower limbs].

Objective: To explore the clinical efficacy of different modes of continuous negative pressure wound therapy (NPWT) on venous ulcer wounds of lower limbs, and to analyze the influencing factors. Methods: From January 2018 to December 2019, 53 patients with venous ulcer of lower limbs who met the inclusion criteria and hospitalized in the Affiliated Hospital of Jiangnan University were recruited in this prospective randomized controlled study. According to the random number table, the patients were divided into single negative pressure therapy (SNPT) group (19 patients, 11 males and 8 females), cyclic alternating negative pressure therapy (CANPT) group (17 patients, 12 males and 5 females), and routine dressing change (RDC) group (17 patients, 10 males and 7 females), aged (47±11), (49±10), and (47±10) years respectively. After admission, patients in SNPT group were given continuous NPWT with the single negative pressure setting at -13.3 kPa, patients in CANPT group were also given continuous NPWT but with the cyclic alternating negative pressure setting from -16.0 to -10.7 kPa, while patients in RDC group were given dressing change with vaseline gauze soaked with iodophor. The wound healing rate was calculated on treatment day 7 and 14. Transcutaneous oxygen pressure (TcPO(2)) around the wound was detected by TcPO(2) meter before treatment and on treatment day 7 and 14. The wound exudate/drainage fluid was collected on treatment day 1, 4, 7, 10, and 14, with the pH value measured using a pH meter, and the volume of exudate/drainage fluid recorded. Before treatment and on treatment day 7 and 14, venous blood was collected to detect the serum levels of interleukin 1ß (IL-1ß), IL-6, tumor necrosis factor α(TNF-α), transforming growth factor-ß(1) (TGF-ß(1)), vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF). Before treatment and on treatment day 7 and 14, wound exudates were collected for bacterial culture, and Visual Analogue Scale and Hamilton Anxiety Scale were used to evaluate the degree of wound pain and anxiety of patients respectively. The length of hospital stay and the total treatment cost were counted. Analysis of variance for repeated measurement, one-way analysis of variance, least significant difference test, Kruskal Wallis H test, Mann Whitney U test, chi-square test, Fisher's exact probability method test, and Bonferroni correction were used to analyze the data. According to the wound healing rate on treatment day 14, the efficiency of patients were divided into two grades of significant healing with wound healing rate≥70% and non significant healing with wound healing rate<70%. According to the two categories of wound healing rate as dependent variables, the levels of TcPO(2), IL-1ß, IL-6, TNF-α, TGF-ß(1), VEGF, bFGF levels and bacterial detection, wound pain and anxiety before treatment, wound exudate/drainage fluid volume and pH value on treatment day 1 were taken as covariates, and binary classification multifactor logistic regression analysis was used to analyze the risk factors of significant wound healing. Results: (1) On treatment day 7, the wound healing rate of patients in SNPT group was (33±10) %, which was significantly higher than (24±9) % of RDC group (P<0.05). On treatment day 14, the wound healing rates of patients in SNPT group and CANPT group were (71±15)% and (66±18)%, respectively, which were significantly higher than (45±19)% of RDC group (P<0.01). (2) Compared with those of RDC group, the TcPO(2) value around the wound of patients was significantly increased in SNPT group on treatment day 14 and in CANPT group on treatment day 7 and 14 (P<0.05 or P<0.01), the pH value of wound drainage fluid of patients was significantly decreased in SNPT group on treatment day 10 and 14 and in CANPT group on treatment day 7 and 14 (P<0.05), the volume of wound drainage fluid of patients was significantly reduced in SNPT group on treatment day 10 and 14 and in CANPT group on treatment day 7, 10, and 14 (Z=-4.060, -4.954, -2.413, -4.085, -4.756, P<0.05 or P<0.01), the serum levels of IL-1ß, IL-6, and TNF-α of patients were significantly decreased in SNPT group and CANPT group on treatment day 7 and 14 (P<0.01), the serum level of TGF-ß(1) of patients was significantly increased in CANPT group on treatment day 14 (P<0.05), the serum levels of VEGF and bFGF were significantly increased in SNPT group and CANPT group on treatment day 14 (P<0.01), the bacteria detection proportion of wound exudate, wound pain, and anxiety scores of patients were significantly decreased in SNPT group and CANPT group on treatment day 7 and 14 (P<0.01). Compared between the negative pressure therapy two groups, except the wound pain score of patients in CANPT group was significantly lower than that in SNPT group (P<0.01) on treatment day 7, the other indicators mentioned above were similar. (3) The length of hospital stay of patients in SNPT group was similar to that in CANPT group (P>0.05), which were significantly shorter than the time in RDC group (P<0.01). The total treatment cost of patients among the three groups was similar (F=1.766, P>0.05). (4) Before treatment, the serum levels of TNF-α and bFGF, TcPO(2) around the wound, and the degree of wound pain were risk factors for significant wound healing (odds ratio=1.109, 0.950, 1.140, 2.169, 95% confidence interval=1.012-1.217, 0.912-0.988, 1.008-1.290, 1.288-3.651, P<0.05 or P<0.01). Conclusions: Clinical application of continuous NPWT under single negative pressure mode and cyclic alternating negative pressure mode has a positive effect on improving the wound base and healing rate of venous ulcer of lower limbs. But cyclic alternating negative pressure mode is significantly more effective than single negative pressure mode in improving TcPO(2) around the wound, reducing wound pH value, reducing exudate volume and relieving pain. The serum levels of TNF-α and bFGF, TcPO(2) around the wound and the degree of wound pain were the risk factors that affect the wound healing significantly.

[Repair of pressure ulcers in ischial tuberosity of 15 patients by partially de-epithelialized posterior femoral bilobed flaps].

Fifteen patients with sinus-type pressure ulcer in ischial tuberosity were admitted to our unit from April 2013 to April 2017, including 12 patients of unilateral pressure ulcer and 3 patients of bilateral pressure ulcer. The wounds were with infection of different degrees. The outer wound area of pressure ulcer before debridement ranged from 1.5 cm×1.0 cm to 6.0 cm×5.0 cm. Fifteen patients with 15 pressure ulcers were treated with vacuum sealing drainage for 3 to 13 days after debridement and sinus wall resection. Unilateral pressure ulcer was repaired with posterior femoral bilobed flap. One side of bilateral pressure ulcer was repaired with posterior femoral bilobed flap, and the other side was repaired with gluteus maximus muscle flap combined with local flap. The size of flaps ranged from 11.0 cm×7.5 cm to 15.0 cm×10.0 cm. Epidermis of the distal part and edge of the main flap was removed to make complex dermal tissue flap to fill the deep cavity. The other part of the main flap was applied to cover wound, and another flap of the bilobed flap was applied to cover the donor site where main flap was resected. The donor sites were sutured directly. The posterior femoral bilobed flaps in 15 patients survived after operation. Pressure ulcers of 12 patients were healed well. Incision of 2 patients ruptured and healed 15 days after second sewing. One pressure ulcer with infection under the flap healed on 16 days post second completely debridement. During follow-up of 3 to 18 months, flaps were with soft texture, good appearance, and no recurrence.

Growth of the fetal forehead and normative dimensions developed by three-dimensional ultrasonographic technology.

Sonographic imaging of the fetal face is important since a number of chromosomal aberrations are associated with facial malformations. In the past, imaging of the fetal forehead and diagnosis of frontal bossing had been based on subjective evaluation using two-dimensional ultrasonography. The purpose of this study was to evaluate quantitatively the fetal forehead using three-dimensional technology to generate normative data throughout gestation. This should allow the objective diagnosis of abnormal growth of the fetal forehead, such as frontal bossing. We also report a case of a fetus with frontal bossing in whom the generated nomogram was applied. A cross-sectional study was performed in 130 normal healthy singleton pregnancies between 16 and 38 weeks' gestation. Using three-dimensional ultrasonography, a line connecting the apex of the philtrum and the nasion was drawn across the anterior forehead, which delineated the area of the forehead for analysis. The forehead length, forehead height, and forehead area under the curve were measured and the forehead index was calculated. A second order polynomial growth function was noted throughout gestation for the forehead length (r = 0.93), forehead height (r = 0.97), and forehead area (r = 0.97). The fetal forehead index remained relatively constant throughout gestation. The results of this study provide normative data of fetal forehead length, width, and area using three-dimensional ultrasonographic technology. Normative dimensions of the fetal forehead developed and presented herein are expected to serve as a basis for the objective assessment of presumed fetal facial abnormalities and may facilitate the detection of the associated syndromes. This is demonstrated in our case report of an achondroplastic fetus in whom all forehead dimensions were above the 95th percentile.

Congenital depression of the fetal skull: case report and review of literature.

Congenital skull depression in babies delivered by cesarean section (C/S) is an extremely rare occurrence and its etiology is frequently unknown. Such depression may be associated with brain injury and permanent cosmetic deformity. Surgical therapy is not the only choice since cranial CT is useful for identification of intracranial damage. In our case, CT scan revealed no intracranial injury and neurological examination of the baby was normal. Thereafter, the baby was managed expectantly and spontaneous resolution of the skull depression was noted by 14 weeks of age.